Blissoma Skin Evaluation
Thank you for contacting us to request a holistic skin consultation! We have been providing in-depth assistance to our customers for years, and helping you achieve healthy skin is our passion. We are honored you have chosen to reach out to us.
Please take the initial intake questionnaire below. It will help us to have a more effective dialogue about your skin and needs.
All your answers are kept confidential to protect your privacy. Please do answer honestly and thoroughly so that we will have the most complete information to be able to help you. Some questions are optional.
Let's create healthy, beautiful skin together!
What is your age range?
12 - 18 years old
18 - 25 years old
25 - 35 years old
35 - 45 years old
45 - 55 years old
City where you live
State where you live
Country where you live
What is your skin color?
What are your current goals for your skin and what would you like to achieve by working with us?
Are you currently using any Blissoma skincare products? If so please list which products you are using and how you feel they are working for your skin.
Please select all statements that apply to describing your skin's oil production and hydration level.
Oily all over
Oily in the "T zone" (forehead and nose)
Oily and shiny but still feels tight and dry
I feel like most moisturizers are too rich for my skin and make the oiliness worse.
My skin gets shiny part way through the day
My skin does not get shiny throughout the day
My skin constantly feels tight and uncomfortable
My skin is generally comfortable and does not bother me
When I smile it feels like my skin might crack
My skin feels dry even when using a lot of moisturizer
My skin dries out as the day goes on
My skin feels dry in the morning after sleeping
My cheeks are often dry and flaky
Do you have any of these common issues? Check all that apply.
Dark marks after acne breakouts
Dark under eye circles
Under eye puffiness
Hyperpigmentation from sun exposure
Hyperpigmentation from hormonal changes
Rough or bumpy texture to skin
Do you have any known allergies or sensitivities to common skincare ingredients? If so which ones?
Do you have any dietary or internally based allergies or sensitivities to foods or pollen? If so what are they?
What problems (if any) are you currently looking to address in your skincare routine?
What is your current morning skincare routine?
What is your current evening skincare routine?
What brand of products are you currently using and have you been happy with them?
Do you have any problems using essential oils in skincare?
How does your skin react to coconut oil?
I don't know
I break out or have increasing dryness when I use coconut oil on my skin
I don't notice any problems when I use coconut oil on my face.
My skin loves coconut oil
How much time do you spend in the sun?
0 to 30 minutes per day
30 minutes to 1 hour per day
1 to 2 hours per day
2 to 3 hours per day
3 to 4 hours per day
More than 4 hours per day
Do you currently use a sunscreen product on your face, and how often? Is it mineral or chemical based? Please list the brand.
Please describe the foods you commonly eat.
Do you currently follow any dietary restrictions?
Do you notice changes in your skin from winter to summer besides getting a little darker or lighter from sun?
For acne sufferers: Do you notice breakouts from any particular triggers? Check all that you feel apply.
Using unsuitable skincare products
Eating the foods that aggravate my body
My monthly hormone cycle
For acne: How often do you break out?
Once a month or less
At least once a month
A few times a month
Often - a new breakout every few days
Constantly - a new breakout almost daily
For acne: Please select the type of breakouts you get. Check all that apply.
Cysts - Deep subsurface pimples that do not come to the surface
Pustules - Painful, inflamed, red breakouts with fluid (a traditional "pimple")
Whiteheads/ Non sore skin congestion
For acne: Where do your breakouts occur on the face? Check all that apply.
Chin and around the mouth
Chest and upper back are affected as well
For skin allergies: Please describe what happens when you react to something. Check all that apply.
Stinging, tingling or unpleasant sensation
Acne type breakout
It is immediate
It is sometimes delayed
Do you experience redness or extreme flushing in your face at times?
Please list any current health issues you are addressing at this time that you feel comfortable sharing with us. Your answers will be kept private to Blissoma staff.
Are you taking any prescription medications? Please list whatever you feel comfortable sharing with us. Your answers will be kept private to Blissoma staff.
Have you ever been officially diagnosed with a skin disorder by a dermatologist?
What kind of services have you gotten from other skin professionals so far and what were the results?
Is your skin currently irritated? Please describe the quality and duration of your skin disruption if so.
Do you currently use makeup on a routine basis? Please list the brands of products in your current routine if so.
Would you also like recommendations for natural makeup products to go with your skin? If so which types of products?
Please select the statements that best describe your use of green beauty products.
I am a newbie to green beauty.
I am a casual user of green beauty with a number of conventional items still in my routine.
I would like to switch all my products to green beauty.
I am fully committed to green beauty.
All my personal care products are currently naturally based.
Is there anything we have not asked about that you would like to share with us?
Send me a copy of my responses.
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service